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Background: Although the awareness, diagnosis, management of the complications associated with diabetes have improved in African countries over the past decade, surveillance activities in Tanzania and anecdotal reports from other African countries have suggested an increased prevalence of Charcot Neuroarthropathy (CN) over the past few years. Aim: To characterize the epidemiology and the clinical burden of CN in a large diabetes population in Tanzania, and to evaluate outcomes of persons with the condition. Methods: This was a prospective analytic cohort study conducted between January 2013 through December 2015. Following informed consent, patients were followed at the outpatient clinic. Detailed clinical assessments and documented presence of diabetic peripheral neuropathy (DPN), macrovascular disease and microvascular disease were recorded. Education and counseling were part of the follow-up program. Results: 3271 ulcerations were presented at the clinic during the 3-year study period. 571 (18%) met the case definition for CN; all patients had Type 2 diabetes. The prevalence for each of the years 2013, 2014, and 2015 was 19/1192 (1.6%), 209/1044 (20%), and 343/1035 (34%), respectively; the increases in the slope of the trendline was statistically significant ( P  < .001). Conclusion: The prevalence of CN is increasing in the Tanzanian diabetes patient population, and is strongly associated with neuropathy. CN can lead to severe deformity, disability, and amputation. Due to the risk of limb amputation, patients with diabetes must seek immediate care if signs or symptoms appear and avoid delay in seeking medical attention. Early diagnosis of CN by caregivers is extremely important for successful outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Distinguishing between Charcot Neuroarthropathy (CN), osteomyelitis (OM), and CN complicated with superimposed OM in diabetic patients is crucial for the treatment choice. Given that current diagnostic methods lack specificity, advanced techniques, e.g., magnetic resonance imaging (MRI) and 99mTc-HMPAO-WBC Single Photon Emission Computed Tomography (SPECT/CT), are needed. This study addresses the challenges in distinguishing OM and CN., Methods: We included diabetic patients with CN and soft tissue ulceration. MRI and 99mTc-HMPAO-WBC SPECT/CT were used for the diagnosis. The patients were classified into three probability levels for OM (i.e., Definite, Probable, and Unlikely) according to the Consensus Criteria for Diabetic Foot Osteomyelitis (CC-DFO)., Results: Eight patients met the eligibility criteria. MRI, supported by SPECT-CT and CC-DFO, showed consistency with the OM diagnosis in three cases. The key diagnostic features included the location of signal abnormalities and secondary features such as skin ulcers, sinus tracts, and abscesses. Notably, cases with inconclusive MRI were clarified by SPECT/CT, emphasizing its efficacy in challenging scenarios., Conclusions: The primary objective of this study was to compare the results of MRI and 99mTc-HMPAO-WBC SPECT/CT with the CC-DFO score in the diabetic foot with CN and suspected OM. Advanced imaging offers a complementary approach to distinguish between CN and OM. This can help delineate the limits of the disease for presurgical planning. While MRI is valuable, 99mTc-HMPAO-WBC SPECT/CT provides additional clarity, especially in challenging cases or when metallic implants affect MRI accuracy.

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This is the first guideline on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes published by the IWGDF. We followed the GRADE Methodology to devise clinical questions in the PACO (Population, Assessment, Comparison, Outcome) and PICO (Population, Intervention, Comparison, Outcome) format, conducted a systematic review of the medical literature, and developed recommendations with the rationale. The recommendations are based on the evidence from our systematic review, expert opinion when evidence was not available, and also taking into account weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to an intervention. We here present the 2023 Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus and also suggest key future topics of research., (© 2023 The Authors. Diabetes/Metabolism Research and Reviews published by John Wiley & Sons Ltd.)

Objective: To summarize the progress of clinical diagnosis and treatment of diabetic Charcot neuroarthropathy (CNO) of foot and ankle to provide reference for clinical treatment., Methods: The research literature on diabetic CNO of foot and ankle at home and abroad was widely reviewed, and the stages and classification criteria of CNO were summarized, and the treatment methods at different stages of the disease course were summarized., Results: CNO is a rapidly destructive disease of bone and joint caused by peripheral neuropathy, which leads to the formation of local deformities and stress ulcers due to bone and joint destruction and protective sensory loss, which eventually leads to disability and even life-threatening. At present, the modified Eichenholtz stage is a commonly used staging criteria for CNO of foot and ankle, which is divided into 4 stages by clinical and imaging manifestations. The classification mainly adopts the modified Brodsky classification, which is divided into 6 types according to the anatomical structure. The treatment of diabetic CNO of foot and ankle needs to be considered in combination with disease stage, blood glucose, comorbidities, local soft tissue conditions, degree of bone and joint destruction, and whether ulcers and infections are present. Conservative treatment is mainly used in the active phase and surgery in the stable phase., Conclusion: The formulation of individualized and stepped treatment regimens can help improve the effectiveness of diabetic CNO of foot and ankle. However, there is still a lack of definitive clinical evidence to guide the treatment of active and stable phases, and further research is needed.

Diabetic foot ulcers are a complex, multifaceted, and widespread complication of diabetes mellitus. Although there are a multitude of risk factors contributing to diabetic foot ulcer development, pressure and (more recently) shear stresses are two biomechanical metrics that are gaining popularity for monitoring risk factors predisposing skin breakdown. Other areas of diabetic foot ulcers under research include plantar temperature measuring, as well as monitoring wear-time compliance and machine learning/AI algorithms. Charcot arthropathy is another diabetes complication that has a relationship with diabetic foot ulcer development, which should be monitored for development alongside ulcer development. The ability to monitor and prevent diabetic foot ulcer development and Charcot neuroarthropathy will lead to increased patient outcomes and patient quality of life., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Bone in diabetes mellitus is characterized by an altered microarchitecture caused by abnormal metabolism of bone cells. Together with diabetic neuropathy, this is associated with serious complications including impaired bone healing culminating in complicated fractures and dislocations, especially in the lower extremities, so-called Charcot neuroarthropathy (CN). The underlying mechanisms are not yet fully understood, and treatment of CN is challenging. Several in vitro and in vivo investigations have suggested positive effects on bone regeneration by modifying biomaterials with sulfated glycosaminoglycans (sGAG). Recent findings described a beneficial effect of sGAG for bone healing in diabetic animal models compared to healthy animals. We therefore aimed at studying the effects of low- and high-sulfated hyaluronan derivatives on osteoclast markers as well as gene expression patterns of osteoclasts and osteoblasts from patients with diabetic CN compared to non-diabetic patients with arthritis at the foot and ankle. Exposure to sulfated hyaluronan (sHA) derivatives reduced the exaggerated calcium phosphate resorption as well as the expression of genes associated with bone resorption in both groups, but more pronounced in patients with CN. Moreover, sHA derivatives reduced the release of pro-inflammatory cytokines in osteoclasts of patients with CN. The effects of sHA on osteoblasts differed only marginally between patients with CN and non-diabetic patients with arthritis. These results suggest balancing effects of sHA on osteoclastic bone resorption parameters in diabetes.

Charcot neuroarthropathy (CN) is a destructive complication of the joints in patients with diabetes and should be managed from the onset of the first symptoms to avoid joint deformity and the risk of amputating the affected joint. Here, we describe the case of a young 24-year-old patient living with type I diabetes who developed active bilateral CN in both tarsal joints. This case of neuroarthropathy was uncommon due to the bilateral presentation at the same level of the joint. Despite the patient consulting from the beginning of the symptoms, none of the physicians suspected or diagnosed CN, leading to a delay in management and the aggravation of bone destruction by CN. This highlights the importance of early management of CN with the need to refer people with suspected CN to specialised diabetic foot care centres.

There are multiple factors that lead to the development of the diabetic foot ulceration (DFU). The ultimate goal when treating DFU is to prevent amputation. Initial therapy should include debridement, maintaining a healthy wound environment, and offloading. In the setting of infection or a nonhealing DFU, surgical intervention may be necessary. The goals of this article are to discuss the key aspects of the initial examination, standard nonoperative treatment, and the operative treatment options for patients with DFU., Competing Interests: Disclosure D.K. Wukich is a consultant for Orthofix, Stryker Wright and receives royalties from Arthrex. He is also on the executive board of the International Association of Diabetic Foot Surgeons. K.M. Raspovic is a consultant for Orthofix. M.J. Johnson has no disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Surgical reconstruction of Charcot arthropathy in the foot and ankle is extremely difficult. The fundamentals of reconstruction are necessary to provide adequate outcome. Removing and resecting the diseased bone is needed along with good anatomic alignment and rigid fixation. This reconstructive surgery is not only difficult from medical management point of view but also involves patient compliance and good technical components of the surgery from the surgeon. The surgeon must have skills with internal and external fixation, a good understanding of lower extremity vascular disease, and a good understanding of infectious disease and plastic surgical techniques of the lower extremity., Competing Interests: Discloser Relative to this article, there are no disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The Charcot diabetic foot presents unique challenges to the podiatric surgeon in the quest to salvage the limb. This disorder is an intersection of prototypical metabolic diseases and neurodegenerative disorder. Furthermore, it can be considered a disease of bone and ligaments that is often complicated by peripheral vascular disease and serious deep infection. Presently, simplistic ablative surgical procedures and the brace-makers art, still have a valid place in treating this disorder. Newer methods of surgical reconstruction are rapidly evolving to address distorted and nonfunctional limb. This article seeks to evidence the principles and practice of beaming the Charcot midfoot. As will be presented, the beam is a load-sharing device, which can be surgically introduced in an intramedullary method to restore architecture and strength to the Charcot foot. Problems with beam failure and migration have resulted in unsatisfactory outcomes as will be discussed. New Charcot-specific beams are currently reaching the podiatric surgeon with hopes of improving durability. In this article, we aim to address the surgical art of the beam, the engineering principles of beaming, and the novel introduction of a truss/tie rod configuration of beaming., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Diabetes mellitus with the lack of glycemic control increases risks for developing comorbidities affecting organ systems responsible for critical function. The development of diabetic neuropathy predisposes patients to the onset of Charcot neuroarthropathy (CN). There is significant complexity with treatment of diabetic-induced CN, which can have an often delayed or missed diagnosis. Supervision and treatment from trained specialists are required to provide care for this multifaceted disease process. It is essential for patients to partner with glucose control, comorbidity prevention and care, as well as lower extremity management. Ultimately, CN can result in significant lower extremity deformity placing patients at risk of limb and life., Competing Interests: Disclosures The author has nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Charcot can be a difficult clinical entity to diagnose in the acute phase, and clinicians should have a high clinical suspicion in neuropathic patients who present with erythema, edema, and warmth of the foot or ankle. Immobilization and nonweight-bearing should be immediately initiated when the diagnosis of Charcot has been made and patients should remain nonweight-bearing until the affected bones/joints have coalesced. Educating patients and managing expectations is crucial to improve compliance with the conservative treatment of Charcot and avoid the long-term sequelae including severe deformity, ulceration and infection, and amputation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Infection imaging has been an important part of nuclear medicine practice. Infections in prosthetic joints and diabetic foot are associated with devastating complications, posing substantial challenge for both diagnosis and overall management. For many years, conventional nuclear medicine techniques have been used to frame a painful joint arthroplasty or diabetic foot infection. The various functional nuclear imaging modalities used include labeled leukocyte imaging, combined leukocyte-marrow scintigraphy, antigranulocyte antibody scintigraphy, 3-phase bone scintigraphy, and fluorodeoxyglucose PET/computed tomography, yet no single method has proved to be highly sensitive and specific and at the same time safe, simple, and time-effective., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

We describe here the case of a female patient with type I diabetes who developed active Charcot neuroarthropathy in the foot. Due to therapeutic noncompliance, talus necrosis was discovered 2 years after the presentation of neuroarthropathy. The impact of untreated neuroarthropathy on the bone is commonly described as fracture and joint dislocation, but we describe the complete disappearance of the bony structure and its necrosis associated with active neuroarthropathy in a patient who refused offloading.

Introduction: Diabetic peripheral neuropathy leads to foot deformity, soft tissues damage, and gait imbalance, all of which can increase the mechanical stress imposed on the foot and give rise to Charcot neuroarthropathy. The current International Working Group of the Diabetic Foot International Guidelines on offloading focus on managing neuropathic foot ulcers related to pressure: only 2 of their 9 recommendations deal with surgical interventions. We assess the role of surgical techniques in off-loading to heal and possibly prevent diabetic foot ulceration., Methods: We systematically analysed published data from January 2000 to November 2020 to assess methods of surgical offloading and associated outcomes for the surgical reconstruction. We tried to identify healing, remission-rates, return to ambulation, complications and limitations., Results: Five discrete categories of surgical offloading are used in recalcitrant ulcers: 1. Lesser toe tenotomies; 2. Metatarsal head resection ± Achilles tendon release; 3. Hallux procedures; 4. Bony off-loading procedures in the form of exostectomy; and 5. Complex surgical foot reconstruction. Adjuvant modalities including surgically placed antibiotic delivery systems show promise, but further studies are required to clarify their role and effect on systemic antibiotic requirements., Conclusions and Implications: Surgery is important to mechanically stabilise and harmonise the foot for long term off-loading and foot-protection. Surgery should not be reserved for recalcitrant cases only, but extended to ulcer prevention and remission. Further comparative studies will benefit surgical decision making to avoid recurrence and define time point when surgical off-loading could protect against irretrievable tissue loss/re-ulceration., (Copyright © 2021 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Introduction: Charcot neuroarthropathy (CN) is an inflammatory arthropathy associated with bony destruction, dislocation, and deformity in patients with neuropathy. Surgical procedures involving foot and ankle in CN for deformity correction have been shown to result in high rate of complications. The purpose of this study was to compare post-operative outcomes and assess odds of complication after ankle arthrodesis among patients with diabetes-related Charcot neuroarthropathy, non-Charcot patients with diabetes, and non-Charcot patients without diabetes., Methods: The PearlDiver Patient Records Database was queried for patients who underwent ankle fusion and maintained at least one year of post-operative follow-up. The following post-operative complications were assessed among groups: overall nonunion and amputation, one-year nonunion, amputation, and hardware removal, 90-day and 30-day surgical site infection, dehiscence, acute kidney injury, and pneumonia, and 90-day myocardial infarction and deep vein thrombosis. The odds and prevalence of each complication for each group were assessed and compared., Results: Higher rates of amputation (OR 3.43, CI 2.89-4.06), hardware removal (OR 1.63, CI 1.45-1.83), wound dehiscence (OR 1.75, CI 1.44-2.13), acute kidney injury (OR 2.87, CI 2.32-3.54), pneumonia (OR 1.53, CI 1.13-2.07), and surgical site infection (OR 2.46, CI 2.12-2.85), were observed in patients with diabetes-related CN compared to non-Charcot patients with diabetes. In patients without CN, higher rates of nonunion (OR 1.38, CI 1.19-1.61), amputation (OR 2.26, CI 1.74-2.93), surgical site infection (OR 1.57, CI 1.30-1.90), and acute kidney injury (OR 1.57, CI 1.18-2.09) were observed in patients with diabetes compared to patients without diabetes. Time to hardware removal was significantly shorter in diabetes-related Charcot patients compared to non-Charcot patients without diabetes (368.0 ± 446.7 vs 438.5 ± 487.5 days, P < 0.001)., Conclusion: Patients with diabetes demonstrated increased odds of nonunion, amputation, surgical site infection, and acute kidney injury compared to patients without diabetes. In the population of patients with diabetes, odds of most of these complications were further increased with the addition of Charcot diagnosis compared to patients without diabetes. Other local and multisystemic medical conditions, including pneumonia and wound dehiscence, also demonstrated increased odds in patients of CN., Level of Evidence: Cohort study; Level of evidence, 3., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The primary aim was to determine the rate of complications in patients with peripheral arterial disease and diabetic Charcot neuroarthropathy who underwent osseous reconstruction. Complications included delayed healing, dehiscence, and major lower extremity amputation. A review of patients with Charcot neuroarthropathy requiring reconstruction secondary to ulceration or acute infection was performed. Descriptive analysis compared outcomes between those with and without peripheral arterial disease. Bivariate analysis and multivariate logistic regression were analyzed for delayed healing, dehiscence, and major amputation. In a cohort of 284 patients with diabetic Charcot neuroarthropathy who underwent osseous reconstruction, the rate of peripheral arterial disease was 20.8% (59/284). Bivariate analysis for delayed healing found hypertension (p = .0352), peripheral arterial disease (p = .0051), and smoking history (p = .0276) to be statistically significant factors. Delayed healing was 2.012 times more likely in the presence of peripheral arterial disease [OR 2.012 (95% CI 1.088-3.720)]. Bivariate analysis for major lower extremity amputation found renal disease (0.0003) (renal disease: ESRD and CKD) and peripheral arterial disease (0.0001) to be statistically significant factors. Major amputation was 4.414 times more likely in the presence of peripheral arterial disease [OR 4.414 (95% CI 2.087-9.334)]. Peripheral arterial disease was identified in 20.8% (59/284) of diabetic patients who underwent Charcot osseous reconstruction. Peripheral arterial disease increased the risk of delayed healing by 2.012 fold, and increased the risk of major lower extremity amputation by 4.414 fold. The rates of complications in patients with peripheral arterial disease were significantly higher than those without peripheral arterial disease who underwent osseous reconstruction., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Charcot neuroarthropathy is a complication of neuropathy often secondary to diabetes mellitus and most commonly affects the midfoot. In these patients, reconstruction of the foot may be required for limb salvage. A superconstruct technique has previously been described using intramedullary beaming fixation of the midfoot and hindfoot to span the zone of injury. Inclusion of the subtalar joint in the arthrodesis construct is not consistently performed among different surgeons. The aim of this study was to describe midfoot beaming constructs and postoperative complications after midfoot reconstruction with and without subtalar arthrodesis. We reviewed medical records of patients who underwent midfoot Charcot reconstruction with an intramedullary beaming superconstruct. Patients included in the study had at least 3 months of follow-up and had Sanders-Frykberg II/III classification of Charcot neuroarthropathy. Postoperative radiographs were evaluated for evidence of hardware failure at the latest follow-up evaluation. The main variables of interest were: hardware failure or nonunion requiring revision operation, deep infection, and unplanned reoperation. Thirty patients who underwent midfoot reconstruction were included. The mean follow-up was 67.4 ± 25.9 weeks. Twenty-two (73.3%) patients had concomitant subtalar arthrodesis and midfoot beaming. Overall complications were lower in patients with subtalar arthrodesis (40.9%) than those without subtalar arthrodesis (75%) resulting in an odds ratio of 0.271 (0.042-1.338, p = .146). Furthermore, increased number of screws used in the midfoot construct was negatively correlated with complications (r = -0.44, p = .01). An intramedullary midfoot beaming superconstruct with subtalar arthrodesis has previously been proposed to provide better fixation after midfoot beaming Charcot neuroarthropathy reconstruction. Our results suggest including the subtalar joint as part of a superconstruct for the reconstruction of Sanders-Frykberg II/III Charcot results in an 80% lower complication rate than intramedullary beaming alone. We also found an increased number of screws used in the midfoot results in a lower complication rate., (Copyright © 2020 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The objective of this study is to compare risk adjusted matched cohorts of Charcot neuroarthropathy patients who underwent osseous reconstruction with and without diabetes. The 2 groups were matched based on age, body mass index, hypertension, history of end-stage renal disease, and peripheral arterial disease. Bivariate analysis was performed for preoperative infection, location of Charcot breakdown, and post reconstruction outcomes, in patients with a minimum of 1 year follow-up period. Through bivariate analysis, presence of preoperative ulceration (p = .0499) was found to be statistically more likely in the patients with diabetes; whereas, delayed osseous union (p = .0050) and return to ambulation (p ≤ .0001) was statistically more likely in patients without diabetes. The nondiabetic Charcot patients were 17.6 folds more likely to return to ambulation (odds ratio [OR] 17.6 [95% confidence interval {CI} {3.5-87.6}]), and 16.4 folds more likely to have delayed union (OR 16.4 [95% CI {1.9-139.6)]). Subanalysis compared well-controlled diabetic and nondiabetic Charcot neuroarthropathy patients for same factors. Multivariate analysis, in the subanalysis, found return to ambulation was 15.1 times likely to occur in the nondiabetic CN cohort (OR 15.1 [95% CI 1.3-175.8]) compared to the well-controlled diabetic CN cohort., (Copyright © 2020 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes., Method: A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997-2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded., Results: A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction., Conclusion: Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.

The hypothesis laid out in this thesis states that the early changes seen on an MR imaging in those with early Charcot neuroarthopathy may be due to mitochondrial dysfunction. In a Charcot foot, there is movement between bones. In an attempt to prevent this movement, the small muscles of the foot contract continuously when the foot is weight bearing. This contraction takes energy in the form of ATP. However, the reduction of glucose transport into the muscle cells due to insulin resistance / insufficiency, leads to reduction in the ATP producing capacity of the mitochondria. The ATP depletion affects the cell membrane gradient leading to mitochondrial and cellular swelling. These early cellular changes could then be picked up with MR imaging as muscle oedema., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Prior research shows increased foot temperatures are predictive of diabetes-related foot complications. Our aim was to describe normative skin foot temperatures for individuals with diabetic peripheral neuropathy to better inform new technologies. We also explored for potential risk factors which correlate with changes in foot temperatures., Methods: We conducted a retrospective chart review of adult patients >18 years of age with diabetes mellitus and clinically diagnosed diabetic peripheral neuropathy with pedal digital thermometry performed between 2009 and 2018. A total of 58 patients met these criteria. Univariate modeling was based on covariates that may affect foot temperature including age, peripheral arterial disease, toe pressure, seasonality of measurement, smoking pack-years, caffeine use, insulin use, and calcium channel blocker use., Results: In patients with diabetic peripheral neuropathy, mean toe temperatures of 27.67°C (6.300°C), forefoot of 28.58°C (5.36°C), midfoot of 29.21°C (3.81°C), and rearfoot of 29.88°C(3.83°C) were demonstrated. A modest negative correlation between seasonality and toe and metatarsal temperatures ( r = -0.38, P < .05; r = -0.43 P < .01, respectively) was demonstrated. Midfoot temperatures were modestly and positively correlated to the presence of small fiber symptoms ( r = 0.33, P = .03). Positive modest correlation with rearfoot temperatures and amount of pack-year history ( r = 0.30, P = .03) was seen., Conclusion: Normative foot temperatures in neuropathic patients were found to be inversely associated with seasonality at the toe and metatarsal level. Smoking and pack-year history demonstrate modest correlation previously unseen in temperature analyses and warrant further exploration. Normative temperatures in neuropathic patients can better inform new technologies for the prevention of diabetic foot ulcer and Charcot neuroarthropathy.

Diabetic foot attack has an acute and severe presentation that threatens the affected limb and the patient's life. It is a term that arises from the need to identify those patients that require urgent intervention; it conveys a sense of urgency and severity, reminding the term of "time is tissue". The classic presentation is that of a severe infected foot with rapidly progressive necrosis that requires urgent surgery to debride all necrotic tissue and purulent collections, providing an adequate antibiotic treatment. Ischemic diabetic foot attack that demands urgent revascularization and the acute Charcot neuroarthropathy for which primacy is given to diagnostic confirmation and off-loading are also consid ered atypical presentations of diabetic foot attack. The aim of identifying these diabetic foot presentations is to promote rapid intervention to provide adequate and effective treatment, avoiding the most feared complication which is the limb amputation. In the present review, a description of the pathophysiology, clinical presentation, treatment and evolution of the three types of diabetic foot attack is made.

Reconstruction of the diabetic Charcot foot can be a challenge even for the most experienced foot and ankle surgeon. The first portion of this article discusses the preoperative evaluation with an emphasis on factors that can be modified before surgical reconstruction to help optimize surgical results. The second portion of the article focuses on intraoperative methods and techniques to help improve postoperative outcomes. Surgeons should strive to provide high-quality, cost-effective care by optimizing patient selection and perioperative care. Objective measures of patient outcomes will become increasingly important with the transition from volume-based to value-based care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Patients with diabetic Charcot neuroarthropathy (CN) are at high risk for ulcerations and major lower extremity amputations (LEAs). Osseous reconstruction is an important component in ulcer healing and prevention; however, despite such efforts, major LEAs remain a serious postreconstruction concern. The aim of this study was to identify risk factors for major LEA in patients who underwent osseous Charcot reconstruction. A retrospective review was performed on 331 patients with the diagnosis of CN in the foot and ankle treated over a 16-year period. Two hundred eighty-five patients were included after exclusion of those without diabetes. Demographic data, anatomic wound location, surgical interventions, wound healing status, and the level of eventual amputation were recorded. Multivariate logistic regression and Fisher's exact test were used for analysis. All patients had diabetes, neuropathy, or CN and required osseous reconstruction. Risk factors and their respective odds ratios (ORs) are as follows: postoperative nonunion (OR 8.5, 95% confidence interval [CI] 2.2 to 33.5, 0.0023), development of new site of CN (OR 8.2; 95% CI 1.1 to 62.9; p = .0440), peripheral arterial disease (OR 4.3; 95% CI 1.7 to 11.0; p = .0020), renal disease (OR 3.7; 95% CI 1.6 to 8.8; p = .0025), postoperative delayed healing (OR 2.6; 95% CI 1.1 to 6.5; p = .0371), postoperative osteomyelitis (OR 2.4; 95% CI 1.0 to 5.9; p = .0473), or elevated glycated hemoglobin (OR 1.2; 95% CI 1.0 to 1.4; p = .0053). Independent risk factors found to be statistically significant for major LEA in diabetic CN in the setting of osseous reconstruction must be mitigated for long-term prevention of major amputations., (Copyright © 2018 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to identify the most-feared complications of diabetes mellitus (DM), comparing those with diabetic foot pathology with those without diabetic foot pathology., Methods: We determined the frequency of patients ranking major lower-extremity amputation (LEA) as their greatest fear in comparison to blindness, death, diabetic foot infection (DFI), or end-stage renal disease (ESRD) requiring dialysis. We further categorized the study group patients (N = 207) by their pathology such as diabetic foot ulcer (DFU), Charcot neuroarthropathy, foot infection, or acute neuropathic fractures and dislocations. The control group (N = 254) was comprised of patients with diabetes who presented with common non-diabetes-related foot pathology., Results: A total of 461 patients were enrolled in this study and included 254 patients without diabetic foot complications and 207 patients with diabetic foot problems. When comparing patients with and without diabetic disease, no significant differences were observed with regard to their fear of blindness, DFI, or ESRD requiring dialysis. Patients with diabetic foot disease (61 of 207, 31.9%) were 136% more likely (odds ratio [OR] = 2.36; 95% CI = 1.51-3.70; P = .002] to rank major LEA as their greatest fear when compared with diabetic patients without foot disease (42 of 254, 16.5%) and were 49% less likely (OR = 0.51; 95% CI = 0.34-0.79; P = .002) to rank death as their greatest fear compared with patients without diabetic foot disease., Conclusion: Patients with diabetic foot pathology fear major LEA more than death, foot infection, or ESRD. Variables that were associated with ranking LEA as the greatest fear were the presence of a diabetic-related foot complication, duration of DM ≥10 years, insulin use, and the presence of peripheral neuropathy., Levels of Evidence: Level II: Prospective, Case controlled study.

Surgical correction of complex foot and ankle deformities secondary to Charcot neuroarthropathy remains a significant surgical challenge. New technological advancements in hardware have allowed for the use of augmented fixation techniques in midfoot deformity correction, including the use of indication-specific locking plates and beaming techniques that offer enhanced stability. Severe hindfoot deformity management can employ the use of internal fixation, including intramedullary hindfoot nails and circular external fixation frames for limb salvage., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Charcot neuroarthropathy (CNA), commonly known as Charcot foot, is one of the most debilitating complications of diabetes mellitus. Patients with plantar ulcer and osteomyelitis (OM) due to Charcot foot represent a high cost for health systems and society in general. The amputation risk for ulcerated Charcot patients is 12 times higher than general population under 65 years old., Material and Methods: In this article we present the CNA treatment protocol we use in our center. We also make a detailed description of the surgical technique «single stage surgery» with circular external fixation., Results: Our CNA treatment protocol covers the most common presentations of this severe neuropathic complication. With the «single stage surgery» using circular external fi xation we achieve an ulcer-free foot, successful treatment of the OM, correction of the deformity, diminished the cost of treatment, avoided amputation and prevented recurrence of the ulcer., Conclusions: The use of a treatment algorithm based on the current literature, can be an invaluable tool in the treatment of these complex patients. The circular external fixation has proven to be the only reliable tool for treating complex Charcot foot in the context of poor bone stock, active ulcers, soft tissues problems and OM.

Aims: To provide data on hospitalization and incidence rates of Charcot neuroarthropathy (CN) and its relation to lower limbs' amputations/revascularizations in population with diabetes of Italy as well as of one of its regions (Tuscany)., Methods: Hospitalizations with CN diagnosis (codes ICD-9-CM: 7130, 7135, 7138) have been recorded in people with diabetes over years 2003-2013 in Italy and 2008-2015 in Tuscany. Amputations, peripheral vascular disease, revascularizations and infections were likewise evaluated., Results: Between 2003 and 2013 CN hospitalizations were very infrequent in Italy ranging between 14×100,000 and 11×100,000 patients with diabetes. In Tuscany they declined to a minimum of 7×100,000 patients in 2015, after a previous increase to a maximum of 22×100,000 (p=NS for both). Yearly CN incidence remained constant in Italy, declining in Tuscany to a minimum of 3.4×100,000 diabetic patients in 2015 (p=0.047). CN patients were younger and with longer length of hospital stay than those with non-Charcot diabetic foot (p<0.05 for both). Amputation and infection rates were manifold higher in CN patients than in those with non-Charcot diabetic foot, while the revascularization rate was similar in both., Conclusions: Over last decade, in Italy and Tuscany yearly CN incidence and hospitalization rates concerned only a small percentage of patients, remaining constant over years and declining in Tuscany in the last couple of years. CN was significantly associated to younger age, longer hospital stay and greater risk of amputations and infections while the need of revascularization was similar to that of non-Charcot diabetic foot., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Achilles tendon pathologic conditions are implicated in contributing to the development of many diabetic foot complications including diabetic foot ulceration and Charcot neuroarthropathy. Surgical correction of the diabetic equinus deformity has been studied as an isolated or adjunctive treatment when dealing with difficult-to-close diabetic foot ulcerations or when surgically addressing the diabetic Charcot neuroarthropathy foot or ankle. This article reviews the most common indications, complications, and surgical procedures for equinus correction by either a tendo-Achilles lengthening or gastrocnemius recession for the management of diabetic foot conditions., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Foot and ankle ulcerations in patients with diabetic Charcot neuroarthropathy (DCN) occur frequently and can be challenging to address surgically when conservative care fails. Patients with acute or chronic diabetic foot ulcers (DFU) are at continued risk for development of osteomyelitis, septic arthritis, gas gangrene, and potential lower extremity amputation. Concurrent vasculopathy and peripheral neuropathy as well as uncontrolled medical comorbidities complicate the treatment approach. In addition, pathomechanical forces left untreated may contribute to DFU recurrence in this patient population. This article outlines in detail the stepwise approach and options available for durable soft tissue coverage in the DCN patient., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Knowledge of diabetic Charcot neuroarthropathy (DCN) has grown tremendously since this condition was first described in 1936 by William Riely Jordan. Despite advancements in diagnostic approaches and treatment options making DCN limb salvage a more viable option, ongoing and additional research is needed to determine the definitive pathogenesis, which may aid in prevention of the condition. This article chronicles the main developments for the study and management of DCN since 1936 and recommends using the term diabetic Charcot-Jordan foot when specifically managing foot and ankle neuroarthropathy joints in patients with diabetic neuropathy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Charcot neuroarthropathy is a disabling complication of diabetic neuropathy. Prolonged immobilization in a total contact cast (TCC) is among the main treatments. Education of health care professionals in the application of TCC together with well-conducted clinical trials are required to overcome its frequent underuse. There are no established pharmacologic therapies to treat this condition; however, there is an overwhelming need for a new therapeutic approach. Novel targeted drug delivery systems are required to prevent the pathologic bone and joint destruction of the Charcot neuroarthropathy and this may lead to an improved outcome in diabetic patients with this condition., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Triceps surae contracture, or equinus, is a known deforming force in the foot and ankle. Biomechanical studies have shown that ankle equinus significantly alters gait and plantar pressures, and in the diabetic neuropathic patient population, this can propagate plantar ulceration and/or Charcot neuroarthropathy (CN). Surgical correction of equinus is globally and frequently used to aid in plantar wound healing in the neuropathic diabetic patient, with and without CN. Treatment guidelines for equinus correction in this medically complex population are undefined and lack evidence from high-quality published peer-reviewed studies., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Charcot neuroarthropathy (CN) is a difficult problem for the foot and ankle surgeon. If surgery is required, little is known or available regarding the best methods and timing. When the initial attempt of reconstruction fails, revision of CN is even more demanding. One must take in to account all aspects, including nutrition, vascular status, infection control, short- and long-term blood glucose management, as well as other factors requiring laboratory monitoring and consult services. Once optimized, the biomechanics of the deformity can be addressed and decisions can be made on fixation devices., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Numerous techniques have been described for surgical management of the diabetic Charcot foot. External fixation has become a main surgical tool for the reconstructive foot and ankle surgeon when dealing with the ulcerated diabetic Charcot foot. In the presence of an open wound and/or osteomyelitis, staged reconstruction with circular external fixation becomes ideal for salvage of the diabetic lower extremity. Also, circular external fixation can provide simultaneous compression and stabilization, correct the underlying osseous or soft tissue deformities, and surgically offload the diabetic Charcot foot. This article describes a variety of circular external fixation applications for the diabetic Charcot foot., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Diabetic Charcot neuroarthropathy (DCN) poses a great challenge to diagnose in the early stages and when plain radiographs do not depict any initial signs of osseous fragmentation or dislocation in a setting of a high clinical index of suspicion. Medical imaging, including magnetic resonance imaging, computed tomography, and advanced bone scintigraphy, has its own unique clinical indications when treating the DCN with or without concomitant osteomyelitis. This article reviews different clinical case scenarios for choosing the most accurate medical imaging in differentiating DCN from osteomyelitis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Diabetic Charcot neuroarthropathy (DCN) of the foot and ankle is a challenging disease with regard to clinical presentation, pathogenesis, and prognosis. Its surgical management is equally difficult to interpret based on the wide array of options available. In the presence of an ulceration or concomitant osteomyelitis, internal fixation by means of screws, plates, or intramedullary nailing needs to be avoided when feasible. External fixation becomes a great surgical tool when managing DCN with concomitant osteomyelitis. This article describes internal and external fixation methods along with available literature to enlighten surgeons faced with treating this complex condition., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Few data describe the natural history of Charcot neuroarthropathy treated with a total contact plaster cast (TCC)., Methods: A 5 year retrospective analysis of 50 patients presenting with an acute CN, Assessing time to clinical resolution into appropriate footwear and assessing if initial immobilisation device influenced resolution time., Results: During the study period 42 patients (84%) of patients went into remission, 2 died during their treatment, 4 had major amputations, in 2 patients treatment was ongoing. 36 patients were treated with combination offloading devices, 6 were treated with one modality only. Median time to resolution for patients initially treated with a TCC was not significantly shorter than for those treated with a removable below knee boot. 34.9% required re-casting due to clinical deterioration in the removable device., Conclusions: More precise measures of resolution of CN are needed to assess the impact of initial treatment modality on time to resolution., (Copyright © 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Patients with peripheral neuropathy associated with ulceration are the nemesis of the orthopedic foot and ankle surgeon. Diabetic foot syndrome is the leading cause of peripheral neuropathy, and its prevalence continues to increase at an alarming rate. Poor wound healing, nonunion, infection, and risk of amputation contribute to the understandable caution toward this patient group. Significant metalwork is required to hold these technically challenging deformities. Neuropathic Minimally Invasive Surgeries is an addition to the toolbox of management of the diabetic foot. It may potentially reduce the risk associated with large wounds and bony correction in this patient group., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Charcot foot is a serious complication of diabetes, characterized by deformity and overlying ulceration. The condition most commonly affects the midfoot. However, little information is available on the use of a medial plantar artery flap to treat diabetic midfoot ulceration. The purpose of the present study was to evaluate the versatility of ostectomy and medial plantar flap reconstruction for midfoot plantar ulceration associated with rocker-bottom deformity secondary to Charcot foot. Four patients underwent ostectomy and medial plantar flap reconstruction. Before flap reconstruction, the devitalized soft tissues and bone were radically resected. After the infection had been controlled, the ulcerated portion was minimally excised, and the bony prominence underlying the ulcer was removed. A medial plantar artery flap was applied to the ulcer. The donor site was covered with a split-thickness skin graft or artificial dermis. In all patients, the ulcers healed and independent ambulation was achieved. However, 1 patient experienced ulcer recurrence, and subsequent infection necessitated a major amputation. Limb salvage is challenging in the setting of deformity and intractable plantar ulceration. The advantages of medial plantar artery flap reconstruction are that tissues with a rich blood supply are used to cover the exposed bone, and the flap can withstand the pressure and shear stress of the patient's body weight. However, a dominant artery in the foot is sacrificed. Therefore, the patency of the dorsalis pedis artery must be confirmed in every patient. The results of the present study have demonstrated that a medial plantar artery can be an effective alternative for diabetic patients with a plantar ulcer secondary to Charcot foot., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Unlabelled: The aim of this study was to determine the lower extremity amputation and mortality rates of a group of patients who underwent reconstructive surgery using circular external fixation for treatment of diabetic Charcot neuroarthropathy (CN) of the foot and/or ankle. Existing studies regarding lower extremity amputation or mortality rates for diabetic CN of the foot and/or ankle have been performed on mostly conservatively treated patients. The objective of the statistical analysis in this studied population was to understand the difference in overall amputation and mortality rates between the 2 main groups: one with foot and/or ankle ulceration (group 1), and the other without ulceration or osteomyelitis (group 2, control group). Within group 1, 2 subgroups were established: one with osteomyelitis (group 1A) and the other without osteomyelitis (group 1B). Initially, a retrospective analysis of 150 consecutive surgically reconstructed diabetic foot and ankle cases using circular external fixation from January 2005 through December 2012 was conducted. Those which were not supported with the diagnosis of diabetic CN were excluded and the 2 other charts without proper follow-up duration (6 months) for analysis were removed, resulting in the final sample size of N = 116. There were a total of n = 7 (6.0%) below the knee amputations (group 1A = 1, group 1B = 4, and group 2 = 2) with a total of n = 5 mortalities (4.3%) (group 1A = 2, group 1B = 2, and group 2 = 1). The total amount of time for a lower extremity amputation event (n = 7) since the time of surgical reconstruction was 729.43 ± 519.73 days (range 230-1777 days) while for a mortality event (n = 5), it was 1302.00 ± 765.48 days (range 633-2499 days)., Levels of Evidence: Prognostic, Level III: Retrospective study., (© 2015 The Author(s).)

We retrospectively analyzed outcome and risk factors of developing Charcot foot (CF) in 100 patients with type 1 diabetes mellitus who underwent a simultaneous pancreas-kidney (SPK) transplantation. Patients who developed CF after SPK transplantation had significantly higher mortality (56% vs. 18%) and more frequently graft failure (44% vs. 13%). Recipients with CF also experienced acute rejections more frequently (78% vs. 41%). They furthermore had higher pre-transplant values of HbA1c , received cyclosporine and azathioprine more often, and had significantly higher cumulative corticosteroid use. Patients transplanted in an earlier era (1992-1998) received cyclosporine and azathioprine more often and had a significantly higher cumulative corticosteroid use with the higher prevalence of CF. Conversely, patients with diabetes transplanted more recently (1999-2012) received lower doses of corticosteroids as part of their tacrolimus-based immunosuppressive therapy, resulting in fewer CF attacks. In conclusion, development of CF after SPK is associated with poor patient and graft outcome. Poor pre-transplant diabetic control and the use of high-dose corticosteroids are risk factors for the development of CF. We recommend reduction in or even total avoidance of corticosteroids after SPK transplantation. Given the importance of the diagnosis of CF on outcome, a systematic examination of SPK patients' feet is recommended., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: The aim of this study was to evaluate weight-bearing radiographs in patients with and without foot ulcers diagnosed with midfoot Charcot neuroarthropathy (CN) secondary to diabetes mellitus., Methods: One hundred fourteen patients with midfoot CN (50 with foot ulcers and 64 without ulcers) were identified and included in this study. Nine radiographic measurements were made (7 in the sagittal plane and 2 in the transverse plane)., Results: CN patients with foot ulcers had significantly greater deformity when assessing the lateral-talar first metatarsal angle, calcaneal pitch, cuboid height, medial column height, calcaneal-fifth metatarsal angle, talar declination, and lateral tibiotalar angle. Two measurements in the transverse plane (hindfoot-forefoot angle and AP talar first metatarsal angle) were not significantly different between the 2 groups. Of patients with foot ulcers, 24% had a lateral talar first metatarsal angle of less than -27 degrees and 80% had a negative cuboid height., Conclusion: Sagittal plane deformities were more likely to be associated with foot ulceration in patients with CN than transverse plane deformities. Lateral column involvement was associated with a worse prognosis than medial column involvement, thus we believe progressive deformity of the lateral column should be monitored closely to prevent foot ulceration. Lateral column involvement could be identified by a decrease in the cuboid height, decreased calcaneal pitch, and decreased lateral calcaneal fifth metatarsal angle. This study can assist physicians in stratifying the risk for both ulceration and need for surgery in patients with CN based on reproducible radiographic measurements., Level of Evidence: Level III, comparative series., (© The Author(s) 2014.)

Foot ulceration and Charcot neuroarthropathy (CN) are well recognized and documented late sequelae of diabetic peripheral, somatic, and sympathetic autonomic neuropathy. The neuropathic foot, however, does not ulcerate spontaneously: it is a combination of loss of sensation due to neuropathy together with other factors such as foot deformity and external trauma that results in ulceration and indeed CN. The commonest trauma leading to foot ulcers in the neuropathic foot in Western countries is from inappropriate footwear. Much of the management of the insensate foot in diabetes has been learned from leprosy which similarly gives rise to insensitive foot ulceration. No expensive equipment is required to identify the high risk foot and recently developed tests such as the Ipswich Touch Test and the Vibratip have been shown to be useful in identifying the high risk foot. A comprehensive screening program, together with education of high risk patients, should help to reduce the all too high incidence of ulceration in diabetes. More recently another very high risk group has been identified, namely patients on dialysis, who are at extremely high risk of developing foot ulceration; this should be preventable. The most important feature in management of neuropathic foot ulceration is offloading as patients can easily walk on active foot ulcers due to the loss of pain sensation. Infection should be treated aggressively and if there is any evidence of peripheral vascular disease, arteriography and appropriate surgical management is also indicated. CN often presents with a unilateral hot, swollen foot and any patient presenting with these features known to have neuropathy should be treated as a Charcot until this is proven otherwise. Most important in the management of acute CN is offloading, often in a total contact cast.

The combination of simultaneous rupture of a tibialis anterior tendon and Charcot neuroarthropathy of the midfoot in a diabetic patient is a rare and challenging condition that can lead to major complications if not addressed appropriately. This article discusses a tibialis anterior tendon rupture that may have developed before or after the incidence of the diabetic Charcot neuroarthropathy midfoot deformity and raises awareness to potential spontaneous tendon ruptures that may be associated with the diabetic Charcot foot., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The Charcot foot is a problematic clinical entity that worsens in the absence of timely intervention. As of now, based on the ADA consensus report, offloading with TCC continues to remain the mainstay of therapy for CN.1 A standardized approach to the management of CN is depicted in Fig. 1. Furthermore, ongoing inflammatory activity can be controlled with antiresorptive agents, like BPPs and calcitonin; however, data acquired from larger trials with these agents are awaited. Newer agents that target the inflammatory cascade have been identified and applied in limited clinical trials in non-Charcot conditions. Their potential role in the future management of CN has yet to be established., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Distinguishing between Charcot Neuroarthropathy (CN), osteomyelitis (OM), and CN complicated with superimposed OM in diabetic patients is crucial for the treatment choice. Given that current diagnostic methods lack specificity, advanced techniques, e.g., magnetic resonance imaging (MRI) and 99mTc-HMPAO–WBC Single Photon Emission Computed Tomography (SPECT/CT), are needed. This study addresses the challenges in distinguishing OM and CN. Methods: We included diabetic patients with CN and soft tissue ulceration. MRI and 99mTc-HMPAO–WBC SPECT/CT were used for the diagnosis. The patients were classified into three probability levels for OM (i.e., Definite, Probable, and Unlikely) according to the Consensus Criteria for Diabetic Foot Osteomyelitis (CC-DFO). Results: Eight patients met the eligibility criteria. MRI, supported by SPECT-CT and CC-DFO, showed consistency with the OM diagnosis in three cases. The key diagnostic features included the location of signal abnormalities and secondary features such as skin ulcers, sinus tracts, and abscesses. Notably, cases with inconclusive MRI were clarified by SPECT/CT, emphasizing its efficacy in challenging scenarios. Conclusions: The primary objective of this study was to compare the results of MRI and 99mTc-HMPAO–WBC SPECT/CT with the CC-DFO score in the diabetic foot with CN and suspected OM. Advanced imaging offers a complementary approach to distinguish between CN and OM. This can help delineate the limits of the disease for presurgical planning. While MRI is valuable, 99mTc-HMPAO–WBC SPECT/CT provides additional clarity, especially in challenging cases or when metallic implants affect MRI accuracy. [ABSTRACT FROM AUTHOR]

Background: There are uncertainties regarding the diagnostic criteria, optimal treatment methods, interventions, monitoring and determination of remission of Charcot neuro‐osteoarthropathy (CNO) of the foot and ankle in people with diabetes mellitus (DM). The aims of this systematic review are to investigate the evidence for the diagnosis and subsequent treatment, to clarify the objective methods for determining remission and to evaluate the evidence for the prevention of re‐activation in people with CNO, DM and intact skin. Methods: We performed a systematic review based on clinical questions in the following categories: Diagnosis, Treatment, Identification of Remission and Prevention of Re‐Activation in people with CNO, DM and intact skin. Included controlled studies were assessed for methodological quality and key data from all studies were extracted. Results: We identified 37 studies for inclusion in this systematic review. Fourteen retrospective and observational studies relevant to the diagnosis of active CNO with respect to clinical examination, imaging and blood laboratory tests in patients with DM and intact skin were included. We identified 18 studies relevant to the treatment of active CNO. These studies included those focused on offloading (total contact cast, removable/non‐removable knee high devices), medical treatment and surgical treatment in the setting of active CNO. Five observational studies were identified regarding the identification of remission in patients who had been treated for active CNO. We did not identify any studies that met our inclusion criteria for the prevention of re‐activation in patients with DM and intact skin who had been previously treated for active CNO and were in remission. Conclusions: There is a paucity of high‐quality data on the diagnosis, treatment, and prognosis of active CNO in people with DM and intact skin. Further research is warranted to address the issues surrounding this complex disease. [ABSTRACT FROM AUTHOR]